Central Apnea, RT does 180

[DrowzyDave]

Hello all,

Had an interesting experience with my new RT. But first some background . . .

I was diagnosed with sleep apnea in October 2006, got first machine (Respironics Bipap ST and F&P 407) nasal mask in November. After a few weeks was feeling much better, but through Feb and March of 07 started feeling not so good again. Contacted first RT (from the A company) who was really no help at all. Next doctor visit, I mentioned it to my doctor who promptly switched me to the L company.

They switched me to a full face mask (which is what I wanted the other guy to do) and a Resmed VPAP III ST. Am very happy with the new RT. She is very responsive and helped me get a mask that I am comfortable with -- F&P 432. She frequently contacts me and did a pulse oximetry study after about a week or so after switching. And here is where it gets interesting .. .

She called to tell me about the results of the pulse oximetry readings and noted that since I had a big problem with central apneas, she would be interested in switching me to the Adapt SV. She reported that she had a patient on it who was having outstanding results. She said she could not switch me right away but verified who my GP was and said she would contact him.

The next time I spoke to her (regarding a mask issue) I asked her how the switch to the new machine was going. She acted like she had no idea what I was talking about!! I reminded her of her concern over the number of centrals and she said that since my O2 levels had remained in the 90s 90% of the time that the current machine must be working okay. And here is the kicker . . .she said she doesn't think she would be able to make the switch happen and that she wouldn't be contacting my GP. She said the only thing she could do was mention it to her "area manager" and see if she runs with it.

I was shocked but resisted the urge to tell her that that sounds like a business oriented decision rather than a medical oriented decision. I can talk to my GP myself -- we have a pretty good relationship if necessary. Given the number of centrals that I had I am curious if this is something I should pursue.

In the beginning 180 minutes of my study prior to titration, I had 1 OA, 54, OHs, and 127 CAs..

Any suggestions?

Thanks.

Dave

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CPAPopedia Keywords Contained In This Post (Click For Definition): resmed, bipap, Titration

[bookwrm63]

Dave,

I'm sorry I can't help you directly but I would change the title to :Central Apnea and my RT or something that mentions CA's. That will hopefully grab the attention of ChristineQuilts who is very experienced in that area and with those machaines. There are several others as well that will probably jump in.

That is a weird response from her and I hope you get it worked out.

Good luck!

Mary

[dsm]

Yes ChristineQuilts knows that machine (Vpap AdaptSV) better than any of us.

But I guess the issue is if the RT got caught out in that she gave her best advice but then realised that her company would not fund a switch to another machine - esp with the Vpap III S/T & Vpap Adapt SV being at the high end of the price scale.

For someone like yourself with extensive CAs, it seems to me that the best machine on the market would be the one she recommended.

The Vpap III is great for accessing the data - have one myself for data gathering but prefer my PB330 for ongoing use.

DSM

[DrowzyDave]

Thanks, guys. I have edited the title.

Dave

[Lubman]

DroopyDave,

Suggest you talk to your GP.
I have Centrals and have used the ResMed Assist SV for quite a few months. Some people it has helped dramatically, some use it with some extra help from doctor-supervised CO2 rebreathing, and I understand others were not significantly helped by it alone.

I would have a hard time going back to a BiPaP at this point.

Find a lab to conduct a PSG with experience with the ASV.

Good luck --

Respironics also has a new machine which is advertised to help with complex breathing such as centrals.

It's your sleep quality; not your RT's. Keep asking until you get a good response - or change RT's, in my opinion.

Lubman

[Lubman]

We poor tired folks don't always get forum names right the first time

Sorry,

DrowzyDave -- The spell checker can't help you when you mess up the names


Lubman

[DrowzyDave]

We poor tired folks don't always get forum names right the first time

Sorry,
Lubman

That's ok, Lubman. Drowzy or droopy, they both feel the same by the end of the day.

[DrowzyDave]

Find a lab to conduct a PSG with experience with the ASV.

Spoke with my RT regarding different issue and asked her about the "inconsistencies" in her recommendatons. At first she got defensive but when I explained that I was happy with her service but "concerned" that she was getting pressure from her superiors, she relaxed. She admitted that she was indeed getting pressure from her "area manager" but suggested that I talk to my GP and ask her to write a prescription for another PSG with an ASV machine to treat central apneas. I was a little pissed that her area manager was making decisions regarding my health but was impressed that the RT came clean when I challenged her. I have an appointment with the GP on Thursday. I have a couple of questions though.

Do the Resmed Adapt SV machines need to be titrated to an IPAP and EPAP pressure or are they automatic?

Will it work with my F&P 432 or do they only work with Resmed masks?

Thanks for your help.

[Snoredog]

The number of Centrals seen from the diagnostic portion of the PSG can dramatically change once you get to the titration portion. How well you do there is what is important. Did all of the CA's go away on bi-level?

Once you leave the lab you have no way of tracking those Central Apnea events. If they remained during your titration portion you can be assured they are there probably at home. If I were you, I would want a copy of that titration table on Bi-level and see for myself what the CA's did at the different pressures you were titrated at.

Why the 180 degree change? I suspect maybe your doctor may have shot down the RT's idea and told them to stop playing doctor with their patient even though the RT may have been right in suggesting the Adapt SV type machine. But that machine carries a pretty hefty price tag and if still considered experimental by your insurance, probably not covered.

The best thing you can do is make sure you get copies of those titration studies and talk to your doctor about them. Most insurance will only pay for 2 PSG's per year, that can also be a consideration. Your past medical history can also play into those decisions.

I haven't heard much about Respironics new Adapt SV machine since the FDA approval back on March 7th, seems after they got the FDA okay to market we haven't heard much from it. Then the A-Flex machine shows up.

I know if I had to pay any portion of those "experimental" machines, I'd want some kind of assurance or exhange program after 1 year because you know they will be making changes to the firmware at your expense. I would ask my doctor about contacting the factory reps for trialing both machines.

[Lubman]

DD

Do the Resmed Adapt SV machines need to be titrated to an IPAP and EPAP pressure or are they automatic?

Will it work with my F&P 432 or do they only work with Resmed masks?

The ResMed Adapt SV allows the Expiration (End Expiratory Pressure or EEP) to be set. It then works over a range. Most people start with an EEP of 5
in the lab -- I happen to be at EEP =6. Original manufacturer guidance said one could go up to EEP=8 as a starting value.

The machine has a pressure sensor hose that "calibrates" the tubing and mask combination. The manufacturer only recommends using one of their masks. If you ask a sleep lab with experience with the ResMed machine they may have a different opinion on whether it is limited to ResMed masks.

There are others on this forum that do not use the ResMed masks.
I happen to use the ResMed FF Mask.

Hope this helps.

Lubman

[Slinky]

I totally disagree on blaming the RT. It seems pretty obvious to me that she wants to do the best for her patients and she is hampered by her Lincare manager. This is not at all unusual w/the national DME suppliers. The bulk ordering is not done at each local office, it is done on a regional basis. You can be rest assurred the regional is not going to keep many of those top of the line EXPENSIVE machines around!

[DrowzyDave]

If I were you, I would want a copy of that titration table on Bi-level and see for myself what the CA's did at the different pressures you were titrated at.

The centrals seemed to diminish during titration to 10.0, 10.0 and spiked at 12.0, 8.0. At the final pressure of 16, 10, there were none for the last 71 minutes of the study.

Why the 180 degree change? I suspect maybe your doctor may have shot down the RT's idea and told them to stop playing doctor with their patient even though the RT may have been right in suggesting the Adapt SV type machine.

The RT never talked to my doctor. I believe her area manager told her not to. She suggested that I talk to the doctor.

I totally disagree on blaming the RT. It seems pretty obvious to me that she wants to do the best for her patients and she is hampered by her Lincare manager. This is not at all unusual w/the national DME suppliers. The bulk ordering is not done at each local office, it is done on a regional basis. You can be rest assurred the regional is not going to keep many of those top of the line EXPENSIVE machines around!

Slinky, I believe you have hit the proverbial neil on the head, my friend. I don't want some midlevel bean counter standing in between my RT and Doctor when it comes deciding which is the best treatment course for me. I give the RT credit for admitting that she was shot down by her manager and giving me a strategy to work around that. But maybe I am being too generous.

[DrowzyDave]

Saw my GP today (or actually the PA who I usually see) and told her about my dilemna. Also mentioned that the RT or Lincare wanted to put me on oxygen after another oximetry study which showed some pretty strange results. I think the strange results were a fluke since other oximetry studies did not show anything like this. This was two weeks after I was told that I did not need the Adapt SV because my previous oximetry test was fine.

The PA had not heard of the Adapt SV but said she would talk to the doctor about it. She also said she would relay my concerns about the inconsistencies in the RT's recommendations and responses.

She called later this afternoon and said that the doctor wants to switch me to another DME. He was not happy about the situation and suspected that the quickness to add oxygen was due to the fact that lincare sells oxygen.

Saw . . .will start with a new DME and a new oximetry study. Have not heard a decision about a new PSG with Adapt SV but suspect it may happen once the doc familiarizes himself with the machine (hopefully)

[Niko]

Dave,

The Adapt SV from ResMed hands down is the way to go for CA's period. Insurance wise, it is covered under the E0471 code (bilevel w/ backup). The Central Apnea pathway is very easy to qualify the Adapt ever since they removed the requirement where you had to desat for over 5 minutes at 88% or less. If you are currently on a Bipap ST then switching to an adapt will not renew the reimbursement for your DME, If you are on a regular biPap (E0470) then switching to a new device, new code your DME will get a brand new reimbursement.

But insurance and all that aside, it is THE most expensive machine out there (it is a servo ventilator) BUT it is the BEST period. Respironics has a similar one (or so they claim) out now, but it is unproven, only benchmark studies and it remains to be seen how it works, a couple of docs on the east coast (boston and philly) who have titrated on it say the waveform the machine delivers is square and looks and behaves like a normal BiPAP, whereas the Adapt SV has a very unique ocean wave form which mimicks a patients own breating waveform. Also ResMed has had 6 years experience in Europe and 1 year here in the states withthe Adapt Sv and thousands of treated patients.

GOOD LUCK!

[DrowzyDave]

The Adapt SV from ResMed hands down is the way to go for CA's period. Insurance wise, it is covered under the E0471 code (bilevel w/ backup).. If you are currently on a Bipap ST then switching to an adapt will not renew the reimbursement for your DME, If you are on a regular biPap (E0470) then switching to a new device, new code your DME will get a brand new reimbursement.

I am currently on a BiPap ST which helps explain why the "area manager" didn't like the idea of switching. I wonder if I will get the same reaction from the new DME if my doctor prescribes a BiPAP ST and then decides to switch to the Adapt after a new PSG?

Dave